Al-Azhar Med. J.
45(4), October 2016, 833-845
DOI: 10.12816/0034746
REVIEW ARTTICLE:
ANESTHETIC MANAGEMENT FOR HIGH RISK
OBSTETRIC EMERGENCIES
By
Mohammed Hussien Ali , Alaa Al Deen Mahmoud Said
and Ahmed Sabry Mohammed Mahmoud
Department of Anesthesia and Intensive Care, AL-Azhar University, Faculty of Medicine
INTRODUCTION
Pregnancy and parturition are
considered “high risk” when accompanied
by conditions unfavorable to the well-
being of the mother, the fetus, or both.
Maternal problems may be related to
pregnancy such as preeclampsia-
eclampsia and other hypertensive
disorders of pregnancy, or antepartum
hemorrhage resulting from placenta previa
or abruption placentae. Diabetes mellitus,
cardiac, chronic renal, neurologic, or
sickle cell disease and asthma, obesity,
and drug abuse are not related to
pregnancy but are often affected by it.
Advanced maternal age (AMA) is
associated with an increased risk of
maternal and fetal complications.
Prematurity (gestation of <37 weeks),
postmaturity (≥42 weeks), intrauterine
growth retardation, and multiple gestation
are fetal conditions associated with risk.
During labor and delivery, fetal
malpresentation (breech, transverse lie),
placental abruption, compression of the
umbilical cord (prolapse, nuchal cord),
precipitous labor, or intrauterine infection
(prolonged rupture of membranes) may
833
Vol.
increase the risk to the mother or the fetus
(Braveman et al., 2013).
Anesthetic management of high risk
pregnant female is based on the
considerations as in healthy mother or
fetus which would include maintenance of
maternal cardiovascular function and
oxygenation improving utero-placental
blood flow and delivery of an infant
without significant drug effect (Arendt,
2016).
Anesthesiologists often contribute to
the care of obstetric patients at high risk in
the peripartum period. The anesthetic
issues involved in caring for woman at
high risk with diseases or conditions
unrelated to their pregnancy that
complicate their obstetric or their obstetric
anesthesia care. Appropriate anesthetic
management can assist in the obstetric
management of these women. Antepartum
consultation between the obstetrician,
anesthesiologist, and specialist managing
the pregnant woman’s chronic condition
will help assure the best outcome possible
for both the mother and her child(ren)
(Sunanda and Seema, 2016).
834
MOHAMMED HUSSIEN ALI et al.

Maternal hemorrhage hypocoagulability. Likewise, infusion of

excessive amounts may increase
Hemorrhagic complications can arise
hemorrhage and mortality due to the so-
at almost any point during pregnancy,
called “dilutional coagulopathy”
labor, and delivery, quickly turning an
(Ekelund et al., 2014).
uneventful pregnancy into an emergent
Transfusion with O Rh (D) negative
situation requiring prompt aggressive
blood must be prioritized, prior to
treatment to ensure the health and
obtaining the initial hemoglobin count, or
wellbeing of mother and infant (Arendt,
other standard laboratory tests.
2016).
Transfusion of PRBC(Packed red blood
Postpartum hemorrhage (PPH) is a cell), Fresh frozen plasma (FFP) and
potentially life-threatening albeit platelets should follow a transfusion
preventable condition that persists as a protocol in accordance with national or
leading cause of maternal death. international transfusion guidelines
Identi? cation of safe and cost-effective (Stensballe et al., 2014).
hemostatic treatment options remains
Peripartum hemorrhage should be
crucial as a supplement to surgery and
manged by multidisciplinary team. An
uterotonic agents (Ekelund et al., 2015).
escalating management protocole
PPH requires early recognition, including uteritonic drug, surgical and/or
immediate control of the bleeding endovascular interventions, and
(including medical, mechanical and procoagulant drugs should be available
surgical interventions), rapid stabilization (Rossaint et al., 2016).
of the patient, and early activation and
● Risk awareness and early recognition of
involvement of multi-professional and
severe hemorrhage are essential.
multi-disciplinary clinical management
(Kozek-Langenecker et al., 2013). ● Patients with known placenta accreta
are treated by multidisciplinary care
Uncontrolled bleeding is a life-threa-
teams.
tening condition and requires emergency
intervention due to hemodynamic ● Cell salvage is well tolerated in
instability. Based on a extrapolation of obstetric settings, provided that
knowledge from trauma management to precautions are taken against rhesus
the PPH situation, and before transfusing isoimmunisation.
packed red blood cells (PRBCs) (De ● Using perioperative cell salvage during
Lange et al., 2014). cesarean section may decrease
The initial treatment of uncontrolled postoperative homologous transfusion and
PPH is often administration of intravenous reduce hospital stay.
? uids (crystalloids or colloids), since ● Moderate(<9.5g/dl) to severe (<8.5g/dl)
anemia is better tolerated than postpartum anemia be treated with
hypovolemia, regardless of the cause of intravenous iron rather than oral therapy.
? uid loss. Crystalloids are often the
preferred choice since colloids may
induce coagulopathy and

REVIEW ARTTICLE: ANESTHETIC MANAGEMENT FOR HIGH RISK...
Intravenous iron supplementation
improves fatigue at 4, 8 and 12 weeks
postpartum.
● Treatment with erythropoietin may
correct anemia more rapidly than
treatment with folic acid and iron.
● Fibrinogen concentration in parturients
with bleeding should be assessed as
concentrations <2gm/l may identify those
at risk of severe PPH.
● Platelet count <100 x 109/l at the onset
of labor, particularly combined with
plasma ? brinogen concentration <2.9g/l,
may indicate an increased risk of PPH.
● Thromboelastometry (ROTEM) can
identify obstetric coagulopathy nd
hyper? brinolysis and guide hemostatic
therapy.
● In life-threatening PPH. Transfusion
protocol is applied with a ? xed product
ratio or individualised procoagulant
intervention and factor substitution.
● Administration of tranexamic acid in
obstetric bleeding to reduce blood loss,
bleeding duration and the number of units
transfused.
● Recombinant activated factor VII
(rFVIIa) should only be considered as a
last line therapy because of its
thromboembolic risk.
● Fibrinogen concentration and number
of platelets should be optimized befor
administration of rFV11a (Rossaint et
al., 2016).
Hypertension during pregnancy
Hypertension during pregnancy can
be classified into four categories as
pregnancy- induced hypertension (PIH,
often also referred to as pre-eclampsia-
835
eclampsia), chronic hypertension that
preceded pregnancy (of any cause),
chronic hypertension with superimposed
pre- eclampsia and gestational hyper-
tension (Olson-Chen and Seligman.,
2016).
Complications of hypertension are the
third leading cause of pregnancy-related
deaths, superseded only by hemorrhage
and embolism (Clyburn et al., 2013).
Obstetric Management of Severe Pre-
Eclamapsia and Eclampsia
Obstetric management of patients with
preeclampsia depends on the individual
clinical situation, and can change
abruptly. There is a high rate of cesarean
sections in patients with pre-eclampsia.
General anesthesia or regional anesthesia
are used and can be considered compar-
able and equally useful. The application of
regional anesthesia is preferred. if the
initial criteria, such as normal neuro-
logical status and blood coagulation, are
fulfilled (Van Gelder et al., 2015).
Factors used to determine obstetric
management include
 Severity of the hypertension
 Presence of complications such as
thrombocytopenia and oliguria
 Fetal condition.
Conservative management involves
controlling hypertension in the outpatient
setting, with the goal of vaginal delivery
nearer to term. With more severe cases,
inpatient control is required, using IV
antihypertensives and seizure prophylaxis
(magnesium is used for seizure
prophylaxis in the United States, while
benzodiazepines and barbiturates are more
often used outside the United States). If
preeclampsia cannot be controlled, or if
836
MOHAMMED HUSSIEN ALI et al.

fetal distress occurs in spite of medical both the mother and fetus (Braveman et
management, cesarean delivery may be al., 2013).
the best option to ensure well-being of

Figure (1): Blood pressure control in severe pre-eclampsia and eclampsia . Bateman B ., et
al. American Journal Of Obstetric and Gynecology.(2014) 212: 337.e1-14.

Treatment Of Eclamptic Fits 4) It should also be ascertained that the

patient has not aspirated during an
1) Initial treatment follows the basic prin-
unwitnessed convulsion, chest X-ray
ciples, i.e airway, breathing and
may be indicated.
circulation.
5) Ante-partum, a fit is often accompanied
2) IV access should be obtained.
by a fetal bradycardia (due to maternal
3) 4 gm magnesium sulphate is used to hypoxia)- the primary concern is the
control the seizure. For recurrent wellbeing of the mother. Adequate
seizures a further 2gm bolus of resuscitation and stabilization of
magnesium is given and the maternal condition will resuscitate the
maintenance increased to 20mg/hr fetus (Van Gelder et al., 2015).
(2g/hr).
Preoperative Assessment of Patients
with Hypertension And Pre-Eclampsia

REVIEW ARTTICLE: ANESTHETIC MANAGEMENT FOR HIGH RISK...
● An accurate clinical assessment of
patients with hypertension and/or pre-
eclampsia is essential as the clinical
course, and subsequent management, is
different for women with pregnancy-
induced hypertension, pre-eclampsia and
severe preeclampsia (Prin et al., 2015).
● Assessment (Magee et al., 2014).
1. Frequent blood pressure determinations.
2. Fundus examination.
3. Neurologic examination for knee reflex.
4. Fetal monitoring.
5. Blood studies: CBC, electrolytes, Mg
level clotting studies (P.T, APTT,
platelets, fibrinogen and fibrin- spilt
products).
6. Urine protein, creatinine clearance.
7. Renal and liver function.
8. Central venous pressure(CVP): indica-
ted when diastolic pressure > 105
mmHg or oliguria; patients reciving
magnesium sulphate and
antihypertensive.
9. Urine output.
10. ECG.
11. Magnesium level every 2 hours.
12. Continuous fetal heart rate monitoring
(Bateman et al., 2014).
Management of Pre-Eclampsia and
Pregnancy-Induced hypertension
(Bateman et al., 2014):
The main aims of management are
● To ensure survival of the mother with
minimal morbidity.
● To ensure that the fetus is delivered as
close to term possible.
837
Important aspects in the management
of pre-eclampsia are (Magee et al.,
2014):
● Blood pressure control.
● Prevention of eclamptic fits.
● Fluid balance.
● Delivery of the fetus.
● Effective postpartum care.
● Management of complications, e.g.
eclampsia / HELLP syndrom .
Anesthetic Options:
An aggressive approach to providing
regional anesthesia in patients presenting
with severe preeclampsia should always
be considered in an attempt to reduce
overall risk (Nelson and D’Angelo,
2015).
The following recommendations are
relevant when general anesthesia cannot
be avoided
■ Two anesthesia providers should be
present if at all possible.
■ Thoroughly preoxygenate/denitrogenate
with a tight mask seal whenever possible,
as ? ve minutes of tidal volume breathing
offers a greater safety margin over ? ve
vital capacity breaths alone (Ankichetty et
al., 2013).
■ Prevent hypertension during
laryngoscopy and intubation to reduce
potential complications such as pulmonary
edema and intracranial hemorrhage.
■ Consideration should be given to use of
higher than normal doses of induction
agent (i.e, sodium pentothal up to 7
mg/kg) (Sumikura et al., 2015).
■ Pharmacologic agents which may be
used prior to airway manipulation in
838
MOHAMMED HUSSIEN ALI et al.

addition to standard rapid sequence Patients with severe preeclampsia

induction agents include:
● Hydralazine: at least 20 min prior to
induction
● Labetalol: at least 10 min prior to
induction
● Esmolol: up to 2 mg/kg bolus
immediately prior to induction
● Nitroglycerine: 50–100 mcg boluses
immediately prior to and during
induction as needed
● Sodium nitroprusside: infusion initiated
at 0.5 mcg/kg/min prior to induction
and titrated to effect
● Fentanyl: 100–150 mcg bolus
immediately prior to induction
● Remifentanil: 1 mcg/kg bolus
immediately prior to induction
● Lidocaine: 100 mg during induction
(Braveman et al., 2013).
In severely pre-eclamptic parturient,
niefdipine was associated with lowering
of maternal blood pressure as well as
prolongation of pregnancy and improve-
ment of fetal oxygenation. However,
cardiovascular collapse has been reported
after use of nifedipine in presence of
magnesium sulfate (Datta, 2013).
Intravenous narcotics have also been
used preoperatively to prevent reflex
hypertension. It was proved that giving
200mg of fentanyl and 5mg of droperidol
intravenously prior to induction of general
anesthesia produces great success (Dahan
et al., 2013).
Summary of General Anesthesia for
Cesarean Section In Pre-Eclamptic
Patients (Datta, 2013):
usually have multisystem involvement,
and are at increased risk for signi? cant
obstetric and anesthetic complications.
Anesthetic risks can be reduced by:
● Assessing platelet count when appro-
priate
● Early epidural catheter placement when-
ever possible
● Utilizing spinal anesthesia for urgent
cesarean section when preexisting
catheter is not present.
● Reserving for general anesthesia when
regional anesthesia is contraindicated
● Controlling blood pressure, especially
during general anesthesia
● Preparing for dif? cult airway manage-
ment.
● Monitor the pulse and blood pressure,
ECG, O2 saturation, PCO2, tempera-
ture, neuromuscular block, CVP, and
pulmonary artery lines, if necessary.
● Nonparticulate antacid and metoclo-
pramide should be used cautiously.
● Drugs should be used to counter hyper-
tension during induction and
extubation, if necessary.
HELLP syndrome (hemolysis, eleva-
ted liver enzymes, low platelets) is an
obstetric complication with heterogonous
presentation and multisystemic involve-
ment. It is characterized by microangio-
pathic hemolytic anemia, elevated liver
enzymes by intravascular breakdown of
? brin in hepatic sinusoids and reduction of
platelet circulation by its increased
consumption (Vellosillo and Medina,
2016).

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HELLP syndrome is a severe variant
of preeclampsia whose pathogenesis
remains unclear. Recent evidence and
clinical similarities suggest a link to
atypical hemolytic uremic syndrome
(aHUS) (Vaught et al., 2016). Its
incidence is between 2–12% of all
pregnancies, and in 10–20% of cases of
pre-eclampsia. It occurs during 70% of
antepartum periods and during 30% of
postpartum periods, and emerges mostly
in the ? rst 48 h (Vellosillo and Medina,
2016). The risk of recurrence in a
subsequent pregnancy is estimated at 19-
27% (Magee et al., 2014).
For classic HELLP syndrome, the
Tennessee and Mississippi classifications
propose clinical criteria using platelet
count, lactate dehydrogenase (LDH)
levels, bilirubin and aspartate aminotrans-
ferase (AST) with or without alanine
aminotransferase (ALT) levels to establish
the diagnosis (Vaught et al., 2016). It is
frequently associated with severe
preeclampsia or eclampsia, but can also be
diagnosed in the absence of these
disorders or mild in up to 50% of patients
(Prin et al., 2015).
HELLP syndrome may result in severe
morbidity and mortality to both the
mother and fetus. Disseminated
intravascular coagulopathy (DIC) is the
most frequent severe maternal
complication followed by hepatic rupture
and bleeding. Delivery is the treatment of
choice. but preterm delivery may have
severe consequences to the neonate
(Vaught et al., 2016).
Differential Diagnosis
The differential diagnosis of HELLP
includes acute fatty liver of pregnancy,
gallbladder disease, lupus flare, and
839
thrombotic thrombocytopenic purpura/
hemolytic uremic syndrome. HELLP
syndrome (SH) can be differentiated from
these other conditions based on normal
ammonia levels, mild renal insufficiency,
anemia, and presence of hypertension and
proteinuria (Olson-Chen and Seligman,
2016).
Anesthetic Management
1) The induction of delivery is the only
specific therapy in HELLP syndrome
(Vaught et al., 2016).
2) If no obstetric complications are
present, vaginal delivery is preferred.
3) Delivery by cesarean section is required
in 60% of cases.
4) In the case of cesarean section, epidural
anesthesia can be recommended when
the thrombocyte count is higher than
100.000/mm3, when there are no
coagulation disorders and the bleeding
time is normal (Magee et al., 2014).
5) The choice of regional or general
anesthesia is influenced by the
condition of the parturient and the
fetus.
6) Selection of drugs is influenced by the
presence of liver or renal failure that
could alter drug clearance.
7) Blood glucose concentration may be
monitored to avoid hyperglycemia in
women with HELLP syndrome
(Bateman et al., 2014).
Embolic Disorder during Pregnancy
Pulmonary Thromboembolism
Normal physiological changes of
pregnancy (including increased clotting
factors and altered venous compliance)
increase the risk of deep venous
840
MOHAMMED HUSSIEN ALI et al.
thrombosis. This translates into propensity
for pulmonary emboli during pregnancy.
Additional risk factors include age >35,
cesarean section, bed rest and obesity
(Prin et al., 2015). Recognition of risk
factors and early postoperative ambulation
are important prophylactic measures (Prin
et al., 2015).
Management of pulmonary embolism in
late pregnancy and labor
Patients presenting with pulmonary
embolism in pregnancy should be treated
with supplemental oxygen (to achieve an
oxygen saturation of >95%) and
intravenous heparin,and should be
transferred to a major medical center that
has a maternal-fetal, neonatal, and
cardiothoracic unit for high-risk patients.
In hemodynamically stable patients, a
temporary vena caval filter should be
placed the diagnosis has been confirmed
(Butwick, 2012).
Figure (2): Diagnosis of venous thromboembolism. Morgan .E.S, E .Wilson, et al., Maternal
obesity and venous thromboembolism., International J of Obst Anesthesia(2012)
21, 253-263.
The care of the pregnant patient who
has massive pulmonary embolism either at
term or when suspicion of compromised
fetal status would call for expeditious
cesarean delivery is complex. It requires a
coordination treatment strategy by the
obstetrician, intensives, cardiothoracic
surgeon, anesthesiologist, and interven-
tional radiologist. The approach to the
management of a massive pulmonary
embolism should be individualized and
adapted to changing circumstances.It
could include cardiopulmonary bypass
with surgical embolectomy followed by
cesarean section or percutaneous
mechanical clot fragmentation and
placement of an inferior vena caval filter.
Although thrombolytic therapy is
considered to be contraindicated,
successful outcomes with the use of
thrombolytic therapy during labor have
been reported (Bilger et al., 2014).

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Special Considerations with Neuraxial
Blockade (Varma, 2016):
The American Society of Regional
Anesthesia (ASRA) has the following
recommendations when neuraxial
blockade is needed for patients receiving
antiplatelet or anticoagulant therapy:
■ Neuraxial blockade and indwelling
catheters are safe in patients on aspirin.
■ NSAIDs alone do not significantly
increase the risk of spinal hematoma.
■ COX-2 inhibitors do not cause platelet
dysfunction .
■ Coadministration of antiplatelet and
anticoagulant medications is contrain-
dicated with indwelling epidural
catheters. Clopidogrel must be
discontinued for 7 days before
neuraxial blockade.
■ Spinal or epidural anesthesia is
performed at least 12 hours after the
last thromboprophylaxis dose of
LMWH (enoxaparin 40 mg SC daily)
or dalteparin (5, 000 U units once
daily), and at least 24 hours after the
last full dose of LMWH (e.g.
enoxaparin 1 mg/kg /12h, enoxaparin
1.5 mg/kg /24h, or dalteparin 120 U/kg
/12h).
■ In general, an epidural catheter should
not be removed until 12 hours after the
last prophylaxis dose of LMWH.
■ The first dose of LMWH should be
administered no sooner than 2 hours
after catheter removal.
■ If a single daily thromboprophylaxis
dose of LMWH is administered,
indwelling catheters may be
maintained postoperatively.
841
■ Concurrent use of twice-daily or
therapeutic LMWH and an indwelling
epidural catheter is not recommended.
■ The LMWH dose is delayed for 24
hours if the patient experienced
excessive trauma during attempted
epidural or spinal anesthesia.
■ Neuraxial blocks should not be
performed in patients chronically
taking warfarin unless the warfarin is
stopped and the INR is normal.
■ Neuraxial catheters should be removed
only when the INR is <1.5.
■ For patients receiving an initial dose of
warfarin prior to surgery, the INR
should be checked if the dose was
given >24 hours earlier or a second
dose has been administered.
■ Newer anticoagulants such as thrombin
inhibitors and fondaparinux are
unknown risks due to a paucity of data
and experience. Avoidance of
indwelling catheters is recommended.
Amniotic fluid embolism (AFE)
Amniotic fluid embolism is a rare
catastrophic and life-threatening
complication of pregnancy that occurs in
the setting of a disruption in barrier
between the amniotic fluid and maternal
circulation. The three most common sites
for entry of amniotic fluid into the
maternal circulation are the endocervical
veins, the placenta, and a uterine trauma
site. Multiparous parturients are at
increased risk of amniotic fluid embolism
(Sadera and Vasudevan, 2015).
Signs and Symptoms: The onset of the
signs and symptoms of amniotic fluid
embolism are dramatic and abrupt,
classically manifesting as dyspnea, arterial
842
MOHAMMED HUSSIEN ALI et al.
hypoxemia, cyanosis, seizures, loss of
consciousness, and hypotension that is
disproportionate to the blood loss. Fetal
distress is present at the same time. More
than 80% of these parturients experience
cardiopulmonary arrest. Coagulopathy
resembling DIC with associated bleeding
is common and may be the only
presenting symptom (Sadera and
Vasudevan, 2015).
Diagnosis: The diagnosis of amniotic
fluid embolism is based on clinical signs
and symptoms. These include increased
pulmonary artery pressures and decreased
cardiac output as determined by
measurements from invasive monitors,
and ultimately confirmation of amniotic
fluid material in the parturient's blood
aspirated from a central venous or
pulmonary artery catheter (Sadera and
Vasudevan, 2015).
Treatment: Treatment of amniotic fluid
embolism includes tracheal intubation and
mechanical ventilation lungs with 100%
oxygen, inotropic support as guided by
central venous or pulmonary artery
catheter monitoring, and correction of
coagulopathy. Positive end-expiratory
pressure is often helpful for improving
oxygenation. Dopamine, dobutamine, and
norepinephrine have been recommended
as inotropes to treat acute left ventricular
dysfunction and associated hypotension.
Fluid therapy is guided by central venous
pressure monitoring, keeping in mind that
these patients are vulnerable to developing
pulmonary edema. Treatment of DIC may
include administration of fresh frozen
plasma, cryoprecipitate, and platelets.
Even with immediate and aggressive
treatment, mortality due to amniotic fluid
embolism remains higher than 80%
(Sadera and Vasudevan, 2015).
Maternal arrest:
Maternal cardiac arrest during
pregnancy challenges health care teams
with the simultaneous care of two
critically ill patients, mother and unborn
baby. These challenges are superimposed
upon a general lack of experience in
maternal resuscitative measures by
obstetric health care team because cardiac
arrest in pregnancy is estimated to occur
in < 1:20, 000 women (Lipman et al.,
2014).
The most common causes of maternal
cardiac arrest are hemorrhage, cardiovas-
cular disease (including myocardial
infarction, aortic dissection, and myocar-
ditis), amniotic fluid embolism, sepsis,
aspiration pneumonitis, pulmonary
embolism, and eclampsia, Important
iatrogenic causes of maternal cardiac
arrest include hypermagnesemia from
magnesium sulfate administration and
anesthetic complication (Lavonas et al.,
2015).
Differential Diagnosis: The same
reversible causes of cardiac arrest that
occur in nonpregnant women can occur
during pregnancy.But providers should be
familiar with pregnancy - specific diseases
and procedural complications. Providers
should try to identify these common and
reversible causes of cardiac arrest in
pregnancy during resuscitation attempts
(Jeejeebhoy et al., 2015).
Emergency Cesarean Delivery in
Cadiac Arrest
Evacuation of the gravid uterus relieves
aortocaval compression and may improve
resuscitation efforts. In the latter half of

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pregnancy, Perimortem cesarean delivery
(PMCD) may considerd part of maternal
resuscitation.(Levanos et al., 2015)
Features of the cardiac arrest which
can increase the infant's chance for
survival:
■ Short interval between the mother's
arrest and the infant's delivery.
Survival of the mother has been
reported up to 15 minutes after the
onset of maternal cardiac arrest
(Levanos et al., 2015).
■ Neonatal survival has been documented
with PMCD performed up to 30
minutes after onset of maternal cardiac
arrest (Levanos et al., 2015).
■ Aggressive and effective resuscitative
efforts for the mother (Levanos et al.,
2015).
■ The hysterotomy is performed in
medical center with a neonatal
intensive care unit (Levanos et al.,
2015).
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‫‪REVIEW ARTTICLE: ANESTHETIC MANAGEMENT FOR HIGH RISK...‬‬

‫اﻟﻣﻌﺎﻣﻠﺔ اﻟﺗﺧدﯾرﯾﺔ ﻟﺣﺎﻻت طوارئ اﻟوﻻدة ﻋﺎﻟﯾﺔ اﻟﺧطورة‬

‫ﻣﺤﻤـﺪ ﺣﺴﯿـﻦ ﻋﻠـﻰ ‪ -‬ﻋﻼء اﻟﺪﯾﻦ ﻣﺤﻤﻮد ﺳﯿﺪ ‪ -‬أﺣﻤﺪ ﺻﺒﺮى ﻣﺤﻤﺪ ﻣﺤﻤﻮد‬
‫ﻗﺴﻢ اﻟﺘﺨﺪﯾﺮ واﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة ‪ -‬ﻛﻠﯿﺔ اﻟﻄﺐ – ﺟﺎﻣﻌﺔ اﻷزھﺮ‬

‫ﺗﺨﻀ ﻊ اﻟﻤ ﺮأة اﻟﺤﺎﻣ ﻞ إﻟ ﻰ ﺗﻐﯿ ﺮات ﻓﺴ ﯿﻮﻟﻮﺟﯿﺔ ﺗﺠﻌﻠﮭ ﺎ ﺗﺘﺤﻤ ﻞ ﺿ ﻐﻮط اﻟﺤﻤ ﻞ واﻟ ﻮﻻدة و أﻗ ﺮب ھ ﺬه‬
‫اﻟﺘﻐﯿﺮات ھﻲ اﻟﺘﻲ ﺗﺘﺤﺮك ھﺮﻣﻮﻧﯿ ﺎ ً ﻓ ﻲ ﺣ ﯿﻦ أن اﻟﺘﻐﯿ ﺮات اﻟﺘ ﻲ ﺗﺤ ﺪث ﻓ ﻲ وﻗ ﺖ ﻻﺣ ﻖ ﻓ ﻲ ﻓﺘ ﺮة اﻟﺤﻤ ﻞ ﺗ ﺮﺗﺒﻂ‬
‫ﺑﺎﻟﺘﺄﺛﯿﺮات اﻟﻤﯿﻜﺎﻧﯿﻜﯿ ﺔ اﻟﻤﺼ ﺎﺣﺒﺔ ﻟﻜﺒ ﺮ ﺣﺠ ﻢ اﻟ ﺮﺣﻢ و زﯾ ﺎدة ﻣﻄﺎﻟ ﺐ اﻟﺘﻤﺜﯿ ﻞ اﻟﻐ ﺬاﺋﻲ ﻟﻠﺠﻨ ﯿﻦ وﻣﻘﺎوﻣ ﺔ إﻧﺨﻔ ﺎض‬
‫ﺗﺪاول اﻟﻤﺸﯿﻤﺔ‪.‬‬

‫وﻗﺪ ﺗﺆﺛﺮاﻟﺘﻐﯿﺮات اﻟﻔﺴﯿﻮﻟﻮﺟﯿﺔ واﻟﺘﺸﺮﯾﺤﯿﺔ اﻟﻤﺼﺎﺣﺒﺔ ﻟﻠﻤﺮأة اﻟﺤﺎﻣ ﻞ أﺛﻨ ﺎء ﻓﺘ ﺮة اﻟﺤﻤ ﻞ وﺑ ﺎﻟﻨﻈﺮ أﯾﻀ ﺎ ً‬
‫إﻟﻰ وﺿﻊ اﻟﺠﻨﯿﻦ ﻋﻠﻰ اﻟﻌﻤﻠﯿﺔ اﻟﺘﺨﺪﯾﺮﯾﺔ أﺛﻨﺎء ﻓﺘﺮة اﻟﺤﻤﻞ‪ ،‬و ﻗﺪ ﺗﺆﺛﺮ ﻋﻠﻰ ﺳﻼﻣﺔ اﻷم أﺛﻨﺎء اﻟﺘﺨﺪﯾﺮ‪.‬‬

‫وﺗﻌﺘﻤﺪ ﻧﺴﺒﺔ وﺻﻮل اﻷوﻛﺴ ﺠﯿﻦ ﻟﻠﺠﻨ ﯿﻦ ﻋﻠ ﻰ ﻗ ﺪرة اﻷم ﻟﺤﻤ ﻞ اﻷوﻛﺴ ﺠﯿﻦ‪ ،‬وﻛﻔ ﺎءة ﺿ ﺦ اﻟﻘﻠ ﺐ ﻟﻠ ﺪم‪،‬‬
‫وﺗﺤﺴﻦ اﻟﺪورة اﻟﺪﻣﻮﯾﺔ ﻟﻠﻤﺸﯿﻤﺔ‪ .‬وﻟﺬﻟﻚ ﻓﺈن أى ﺗﺪﺧﻼت ﺗﮭﺪد ھﺬه اﻟﻌﻮاﻣﻞ ﻗﺪ ﺗﺆدى إﻟﻰ إﺧﺘﻨﺎق اﻟﺠﻨﯿﻦ‪.‬‬

‫وﯾﺄﺗﻲ اﻟﻨﺰﯾﻒ ﺣﻮل ﻓﺘﺮة اﻟﻮﻻدة ﻓﻲ ﻣﻘﺪﻣﺔ أﺳﺒﺎب وﻓﯿﺎت اﻟﺤﻮاﻣﻞ‪ ،‬واﻟﺬى ﯾﻨﻘﺴﻢ إﻟ ﻰ ﻧﺰﯾ ﻒ ﻗﺒ ﻞ وأﺛﻨ ﺎء‬
‫وﺑﻌﺪ اﻟﻮﻻدة‪ ،‬وﻗﺪ ﯾﺤﺪث ﺗﺪاﺧﻞ ﻓﯿﻤﺎ ﺑﯿ ﻨﮭﻢ‪ ،‬وﻣ ﻦ أھ ﻢ أﺳ ﺒﺎب ﻧﺰﯾ ﻒ اﻷم ﻗﺒ ﻞ اﻟ ﻮﻻدة ھ ﻮ ﺗﻘ ﺪم اﻟﻤﺸ ﯿﻤﺔ‪ ،‬وﻓﺼ ﻞ‬
‫اﻟﻤﺸ ﯿﻤﺔ‪ ،‬وﻛ ﺬﻟﻚ ﺗﻤ ﺰق اﻟ ﺮﺣﻢ‪ .‬أﻣ ﺎ أﺳ ﺒﺎب ﻧﺰﯾ ﻒ اﻷم ﺑﻌ ﺪ اﻟ ﻮﻻدة ﻓﮭ ﻲ ﺗﺘﻀ ﻤﻦ إرﺗﺨ ﺎء اﻟ ﺮﺣﻢ‪ ،‬واﻟﻤﺸ ﯿﻤﺔ‬
‫اﻟﻤﺘﺤﺠﺮة‪ ،‬وﺗﮭﺘﻜﺎت ﻋﻨﻖ اﻟﺮﺣﻢ واﻟﻤﮭﺒﻞ‪ .‬وﺗﺄﺗﻰ اﻟﺴ ﻤﻨﺔ اﻟﻤﻔﺮط ﺔ أﺛﻨ ﺎء اﻟﺤﻤ ﻞ ﻣ ﻦ أھ ﻢ ﻋﻮاﻣ ﻞ زﯾ ﺎدة اﻟﺨﻄ ﻮرة‬
‫ﻋﻠ ﻰ اﻷم واﻟﺠﻨ ﯿﻦ وﺑﺎﻟﺘ ﺎﻟﻲ ﺗ ﺆدى إﻟ ﻰ زﯾ ﺎدة ﻣﻌ ﺪﻻت اﻟﻤ ﺮض واﻟﻮﻓﯿ ﺎت‪ ،‬ﻓﮭ ﻲ ﺗﻌﻤ ﻞ ﻋﻠ ﻰ ﻣﻀ ﺎﻋﻔﺔ اﻟﺘﻐﯿ ﺮات‬
‫اﻟﻔﺴﯿﻮﻟﻮﺟﯿﺔ اﻟﻤﺼﺎﺣﺒﺔ ﻟﻠﺤﻤﻞ ﻣﻤﺎ ﯾﺆدى إﻟﻰ إرھﺎق ﺟﻤﯿﻊ وظﺎﺋﻒ اﻟﺠﺴﻢ وﺑﺎﻷﺧﺺ اﻟﻘﻠﺐ واﻟﺠﮭﺎز اﻟﺘﻨﻔﺴﻲ‪.‬‬

‫وﯾ ﺄﺗﻲ ارﺗﻔ ﺎع ﺿ ﻐﻂ اﻟ ﺪم أﯾﻀ ﺎ ً ﻣ ﻦ أﺳ ﺒﺎب وﻓﯿ ﺎت اﻟﺤﻮاﻣ ﻞ وﺗﻌﺘﺒ ﺮ اﻹﻋﺘﺒ ﺎرات اﻟﺘﺨﺪﯾﺮﯾ ﺔ ﻟﻤﺮﺿ ﻰ‬
‫اﻟﻀﻐﻂ اﻟﻤﺮﺗﻔﻊ أﺛﻨﺎء اﻟﺤﻤﻞ ﻣﻦ أھﻢ اﻟﻌﻮاﻣﻞ اﻟﺘﻲ ﺗﺴﺎھﻢ ﻓﻲ ﺣﻞ اﻟﻤﺸﻜﻠﺔ وﻋﻼﺟﮭﺎ ‪.‬‬

‫وھﻨﺎك ﺗﻐﯿﺮات ﺑﺎﺛﻮﻓﺴﯿﻮﻟﻮﺟﯿﺔ ﻣ ﺆﺛﺮة ﻓ ﻲ أدوﯾ ﺔ اﻟﺘﺨ ﺪﯾﺮ ﻣﻤ ﺎ ﯾ ﻨﻌﻜﺲ دورھ ﺎ ﻋﻠ ﻰ أﺟﮭ ﺰة اﻟﺠﺴ ﻢ ﻣ ﻦ‬
‫اﻟﻘﻠﺐ واﻷوﻋﯿﺔ اﻟﺪﻣﻮﯾﺔ واﻟﺠﮭﺎز اﻟﺘﻨﻔﺴﻰ واﻟﺠﮭﺎز اﻟﮭﻀﻤﻰ‪ ،‬وھﻨﺎك ﻣﺸﺎﻛﻞ أﺧﺮى ﺗﻮاﺟ ﮫ اﻟﺤﻮاﻣ ﻞ وﺗﺴ ﺒﺐ ﻓ ﻲ‬
‫زﯾﺎدة اﻟﻮﻓﯿﺎت وﻣﻨﮭﺎ ﺗﺴﻤﻢ اﻟﺤﻤﻞ‪ ،‬واﻟﺠﻠﻄﺔ اﻟﺪﻣﻮﯾﺔ‪ ،‬وأﻣﺮاض ﺻﻤﺎﻣﺎت اﻟﻘﻠﺐ‪ ،‬واﻟﻌﯿﻮب اﻟﺨﻠﻘﯿﺔ ﺑﺎﻟﻘﻠﺐ‪.‬‬

‫و ﺗﻌﺘﻤﺪ اﻟﻤﻌﺎﻟﺠﺔ اﻟﺘﺨﺪﯾﺮﯾﺔ ﻓﻲ ﺣ ﺎﻻت اﻟ ﻮﻻدة اﻟﺤﺮﺟ ﺔ ﻋﻠ ﻰ اﻟﻤﺤﺎﻓﻈ ﺔ ﻋﻠ ﻰ وظ ﺎﺋﻒ اﻟﻘﻠ ﺐ واﻷوﻋﯿ ﺔ‬
‫اﻟﺪﻣﻮﯾﺔ وﻧﺴﺒﺔ ﺗﺸﺒﻊ اﻷﻛﺴﺠﯿﻦ ﻓﻲ اﻟﺪم ﺑﺤﯿﺚ ﺗﻜ ﻮن اﻟﻤﻌ ﺪل اﻟﻄﺒﯿﻌ ﻲ ﻣﺜ ﻞ ﺣ ﺎﻻت اﻷم اﻟﻄﺒﯿﻌﯿ ﺔ واﻟﺠﻨ ﯿﻦ اﻟﺴ ﻠﯿﻢ‬
‫ﻟﻀﻤﺎن ﺗﺤﺴﯿﻦ اﻟﺪم اﻟﻮاﺻﻞ إﻟﻰ اﻟﻤﺸﯿﻤﺔ‪ ،‬و وﻻدة طﻔﻞ ﺳﻠﯿﻢ ﺑﺪون ﻣﻀﺎﻋﻔﺎت ﺟﺎﻧﺒﯿﺔ ﻟﻸدوﯾﺔ اﻟﻤﻌﻄﺎة ‪.‬‬